Clinical writing – Dramatherapy and family alcohol or drug problems

When the child proof cap has been left off the medicine bottle – Dramatherapy with Young People Affected by Parental Drug and Alcohol problems.

When the child proof cap has been left off the medicine bottle – Dramatherapy with Young People Affected by Parental Drug and Alcohol problems.

Abstract

Young people affected by drug and alcohol use in their family face profound challenges to avoid repeating the toxic patterns that affect their family life and parent’s ability to parent. Dramatherapy can offer a way of creating psychological space and enabling these young people to begin to engage and play with the heavy images and stories they carry with them. This paper looks at how young people are affected by their parental drug and alcohol problems and how dramatherapy can offer a space for them to engage with problems such as conflicted loyalties, neglect, abandonment, rage, isolation and premature responsibility. It draws on four years of experience offering individual and group dramatherapy to young people, and contemporary approaches to the problem from psychology, social work, psychotherapy and the arts therapies, to help understand and illustrate the uses of a psychological and dramatic space to engage with the diverse problems parental drug and alcohol use create for a child.

keywords: dramatherapy, young people, drug and alcohol problems, family

names and personal details of children have been anonymised to ensure confidentiality, and consent of children and carers given.

When the child proof cap has been left off the medicine bottle – Dramatherapy with Young People Affected by Parental Drug and Alcohol problems.

A group of school children in a dramatherapy group want to create a play about a family with alcohol problems. One of the girls girl, aged 12, produces a perfect enactment of a drunk mother, imitating a drunken older mother very convincingly, complete with weaving walk, giddy hand gestures, sharp childish humour, sudden moodswings and need to be looked after. The “drunk mother” returns home to the house, where her daughter was looking after her infant baby sister. The mother and the daughter argue violently over who is meant to look after the baby. As they argue over the baby, they almost begin to physically fight over who should hold the baby. In the passion and heat of who should look after the baby, the actors have created a scene in which the baby is now at risk from the people that care for it most.

The children of adults with drug and alcohol problems.

This paper is about the effect of drug and alcohol problems not on the user but on their child. I have been working with the children of people with drug and alcohol problems since 2008. When I think about the young people I have met, I do not think of a coherent set of children with the same problems. And yet, in each case there have been problems that could be traced back to a parent’s struggle to cope with being a parent. In each case a parent who feels unable to cope has self medicated with drugs or alcohol. This has affected the child’s life in a significant way, exposing them to their parent’s difficulties in vivid and potentially life-defining ways. A parent’s alcohol or drug problem can expose a child to a set of experiences very different to their peers. They do not have access to the usual safeguards that other children have within parental relationships. The child proof cap has been left off the parent’s medicine bottle and its contents are likely to be poisonous to the child.

2 : The movement towards child centred multi- agency work – Hidden Harm and Every Child Matters
The effects of a parent’s drug and alcohol abuse on a child are hard to quantify. However, the topic of the effect of drug and alcohol use on a child is part of a current and changing agenda, that recognises the social and psychological damage that children can face when their parents have drug or alcohol problems. In 2003, the Hidden Harm report was comissioned by the government, focusing on the children of drug users, highlighted these problems. It became a key document, effecting national policy and made the following recommendations :
There are between 250,000 and 350,000 children of problem drug users in the UK – about 1 child for every problem drug user.
Parental problem drug use causes serious harm to children at every age from conception to adulthood.
Reducing the harm to children from parental problem drug use should become a main objective of policy and practice.
Effective treatment of the parent can have major benefits for the child.
By working together, services can take many practical steps to protect and improve the health and well-being of affected children.
The number of affected children is only likely decrease when the number of problem drug users decreases. 

Since 2003, the focus of professionals working with addiction has shifted to include alcohol more generally. Adfam estimated in a recent briefing to mark the ten years since Hidden Harm that there may be up to five times more children affected by alcohol problems than drugs.The generic term to describe substance misuse is shifting from “substance misuse” to “alcohol and other drugs” to emphasise the fact that alcohol is the drug that is most likely to be used problematically. In the same year, Every Child Matters was published, another government paper published in order to put children more at the centre of professionals working with troubled families. Safeguarding trainings now highlight the primacy of the child where risk to a child is known and the need for co-operative working between different agencies, especially adult and child services. Taken together, these two papers highlight a growing move in the last ten years to protect, understand and support children in situations in which they are vulnerable – and children affected by alcohol and other drug misuse are in this category for multiple reasons.

  1. How do professionals respond to children affected by drug and alcohol problems?
    Each professional role has responded to the problems of working with children affected by drug or alcohol problems showing the stamp of their own discipline. Taken together, they show the spectrum of role responses to the crisis of a child affected by drug and alcohol problems, and so highlight dramatherapy’s role within this spectrum. By considering each, the question of what dramatherapy offers distinct intervention starts to come into clearer focus.

4 Responses to risk – social work, risk assessment and the child

Social workers have statutory responsibility and need to find ways to assess the risk to child. Murphy and Harbin write that “much research suggests that in isolation problem drug use of a parent presents little risk of significant harm” (Harbin et al 2000). Murphy and Harbin offer a frame work to assess the risk to a child from drug or alcohol problems that takes into account a family environment, the parent’s capacity to parent and any signs of a child’s development being checked. These three factors from the basis for making a judgement about whether a particular child may be at risk.

Despite Murphy and Harbin’s caution about jumping to conclusions about drug and alcohol problems, in a different chapter in the same book Allison writes of “clear evidence implicating maternal substance misuse as one of the most significant predisposing risk factors.” (Harbin et al 2000) The risks she cites are wide ranging from poor health and neglect, to developmental delay and a higher likelihood of physical and sexual abuse. She concludes “the links between drug abuse and child abuse and neglect are becoming very clear” (Harbin et al 2000).

Looking at the wider picture around drug and alcohol use and children, Gilman writes “ substance misuse is not a separate issue to social exclusion but an integral intertwined strand”. (Harbin et al 2000) He regards “problem” and non problematic drug use as often reflective of class and status. He writes that considering drug and alcohol problems and how they affect children without consideration of the wider social and cultural environment they occur in may result in unfairly shifting the blame for these problems onto an already vulnerable group. Doing this, he suggests, may be a convenient way of ignoring that drug and alcohol problems may reflect wider social patterns of how wealth and resources are shared within communities.

Social workers have a crucial role to play in the life of children of substance affected children. The assessment of risk comes into the remit of anyone working with a child, especially since the culture shift towards collective responsibility for child safeguarding. Social workers can become key allies in creating a team around the family too, and can be the crucial difference in whether a child is able to access therapy.

5 Clincal Psychology and the search for evidence of child depression

Clinical Psychology, with its remit to better understand psychological problems has looked for evidence of how substance misuse affects the mental health of children of alcoholics and substance misusers. Drucker, a psychologist examining depression and anxiety levels in affected children writes : “Research over the past 20 years suggests that children of alcoholics and substance abusers are at high risk for having a number of psychopathological symptoms as well as for substance abuse.” (Drucker 1997) He suggests that depression and anxiety are likely to be higher in children of drug or alcohol users. Further research he was involved with suggests the distress and depression of a non-substance using mothers becomes matched by their child (Vigorito 1996). Black, who pioneered writing about the effect of alcohol abuse on children, also stresses the role that the non addicted partner can have on a child’s well being, in creating a culture in which the problem partner is always at the centre of the families attention (Black 1991) . The project I work for, Young Oasis, now offers support groups to non-alcohol or drug using partner’s, with a children’s group running in tandem.

These studies seek to discover how alcohol problems affect a child, but they rely on a child answering questions about how they feel, perhaps even with another adult to explain or interpret the questions. The Young Oasis well being questionnaire is like this – often a parent needs to help the child answer, so the results reflect this relationship. The child’s answers need to be understood in the context of that child’s life.

Children of drug and alcohol users have often grown up in environments when disguising how one feels or not talking about a problem may be the normal way of coping with conflicting pressures. This means that the data collected from these questionnaires does not yield simple results and has to be interpreted in the light of what practitioners already know through their relationship with the problems and the children. For example, in an evaluation of its Well Being questionnaire, the boys referred to Young Oasis because of parental drug or alcohol use reported themselves to be happier and better adjusted than average. Clinical experience highlight and professional literature both suggest that denial can be part of the major life of these children. I have taken referrals from children whose mother’s are in a residential rehabilitation centre but the children have not been told where their mother has gone. That the children of parents with alcohol problems should score as above average in a well being measure shows how denial and not talking about a problem can become endemic in families. A parent’s problem becomes a secret the child does not even know they are keeping.

6 : Child Psychotherapy and the affect of adult alcohol problems on a child’s way of creating relationship.

Where social work stresses risk assesment and social factors, and psychology understanding of the mind, the emphasis in psychotherapy has always been on relationship as a medium to bring about psychological change. Since Freud, different theories and applications have been created for working with children psychotherapeutically. However, this constant remains; that within reflective relationship change can occur and that relationship acts as the medium of psychotherapy. Psychotherapy offers a view of the child as absorbed in relational experiences that form and create their sense of self, others and how the world is. When this is disrupted or neglected, a child’s sense of self suffers too. Winnicott refers to the way that physical holding and attention to the child allows the child from the mother allows the child to gain a sense of himself as gradually separate from her. From this perspective, neglect or abandonment becomes a disaster for a child, as they have no consistent means of making sense of themselves or the world. He writes : “If there is no one there to be mother the infant’s task is infinitely complicated” Winnicott p131

The children of alcoholics or substance misusers have parents who even when they are physically present may not be psychologically present. One boy of 10 at the Oasis project said that talking to his mother was like talking to a “brick wall”.

Child psychotherapy, with its emphasis on the attachment patterns of children to their parents, and how they are replicated in other relationships, offers further insight into the way that an alcohol or drug problem can seriously affect a child. Neglect, isolation, higher risks of exposure to crime, becoming a carer for a parent are all higher possibilities, but also that the child’s sense of self becomes incomplete or damaged when their parent is physically but not psychologically present.

Shaikou, a child psychotherapist, examined attachment patterns in children’s drawing who had been maltreated and compared them to a group of “non abused” children. The pictures children who have been maltreated draw of their families often look incomplete. Faces are drawn but not bodies: “schematic bodies, barely outlined, poor in detail with an absence or deformity of the face” (Shiakou 2012). When neglected or maltreated, the images a child creates reflect not only the isolation and conflict in their lives, but in themselves reflect a decay of the imaginative space. Shaikou’s work suggests that child abuse attacks the ability of a child to imagine and be creative. Her work looks at attachment patterns in art. Art and its origins in play has been conceptualised as the “transitional space” between mother and child that Winnicott mapped out in his work (Cattanach 1996).

Therapy means paying attention to this space between therapist and child, which often takes the form of play. Therapy with a neglected child attempts to bring to life the child’s creative space through stimulating it with attention, play and reflection on the meaning of interaction.

However, as Shaikou’s work suggests, this might be difficult when a child has a poor sense of how to play and is unused to being met in play by an adult. One of my recent referrals was 12 year old boy who refused therapy because he said he felt like he it meant having to have therapy for his mother’s problems. Providing therapy to older children affected can be harder, as children become older they may become harder to reach and more likely to not engage. “There is nothing wrong with me, why do I have to come here?” said one girl of 10 in a recent session.

9 :Playing with Abandonment – Charlie
Charlie, was 5 years old when she was referred for individual therapy. At the time, he was living with her mother. Early in the course of therapy, her mother relapsed and began to drink again, and was taken from her mother by social services. Over the course of 9 months, Charlie lived with 3 different sets of carers. Her previous foster parents couldn’t take him in, as they felt they were too old. The next placement was changed at review by a social worker who felt Charlie would benefit from a more stable placement with a couple. All of this left Charlie very vulnerable, and through my work with her I realised just how vulnerable a child like Charlie becomes when they have no consistent adult in their life.
Expressions of Abandonment
Charlie used all the materials in the room from paints, sandbox to small toys, but she particularly focused on two string puppets, one dog and one dog like. They became the focus of a recurring theme in her play, which was about buying pets from a pet shop. She played out this theme in a variety of ways, but most often involving scenarios where a pet was bought from a pet shop and then returned or replaced with a better one. In her games, the puppets sometimes turned on their master and locked him out of his home. At other times, the games experimented with relationship with the one dog switching suddenly and unexpectedly between being friendly and aggressive. This was a theme she returned to quite often; two dogs initially friendly, but one suddenly becomes aggressive, violent and out of control. Charlie found a play that allowed these sadistic and sudden impulses in his characters to find expression.

The need for nourishment
Towards the end of therapy, with her home life seemingly more stable, she surprised me be using the time to play out stable, content fantasies where a mother looked out for her child very carefully and made him a lovely cake or drink. In constrast to the violent and unexpected images of her earlier play, Charlie now wanted to explore a stable, kind fantasy. In doing so, she helped create an atmosphere of peace and kindness in the therapy space. I felt that the movement from her early play to this type of play reflected something nourishing happening in the therapy space. Charlie wanted to take something from the room – a paint pot, or a feather, and I was always clear to her that the toys belonged in the room. She even wanted to take a speck of dust or fluff. I felt she wanted something solid and permanent to take away from what she found in the therapy. It seemed important to hold this boundary with her, so she could focus on the play and the therapy itself, rather than placing it in an object. However, in the final session of therapy I offered her something from the art materials in the room, and after weeks and weeks of wanting to take something, she said she did not want anything. After I felt that by refusing a real object, she was able to take something more valuable with her; the experience and profundity of her own play.

7 Arts therapies as a window into the hidden lives of children with family alcohol or drug problems

Holt and Kaiser researched ways the experience of being a child in a family of alcohol users shows itself in a child’s artwork (Holt 2001). They identified recurring images that they associated as indicators of alcohol problems – images of water, containers for liquids, and depictions of isolation of the self or family unit. The children’s images highlight the effect of isolation in a child’s experience. Holt and Kaiser underline their point through research they quote that shows that “early exposure to familial addiction has a long lasting effects on the child’s ability to sustain adequate intimate relations as an adult” (Holt 2001). Amongst the tables analysing the images and the research about the effects of the problems there were images created by children. Images of families bunkered in houses with thick black walls scrawled in black.

Holt and Kaiser write that “some children may show little overt evidence of problems.” They add “it is important to recognise the easily overlooked child who may fulfil the role of family hero whilst suppressing emotional struggles that place him or her at risk of future problems.” (Holt 2001)

Sometimes children’s “bad” behaviour, anger or even violence can mask a parent’s problems, allowing the focus of shame to shift from parent to child in a concealed transaction that neither may be fully conscious of. One of my referrals thought he was in therapy because of his anger, as that seemed the only way his mother could explain why he was there. In fact, as sessions progressed he revealed a deep sense of shame from his anger and the subtle ways he felt obliged to be angry. Sometimes he felt his mother used the threat of his anger to put pressure on his siblings to do as they were told. His sessions revealed a highly conscientious child and his therapy became more about exploring his confidence and rehearsing a letting go of the responsibility he felt towards his mother and siblings, as a result of the dangerous situations he had experienced through her drinking and drug use.

8 A child’s need for psychological space during parental crisis

So, paradoxically, one of the most important features of a therapeutic service for children who have parents with drug and alcohol problems may be that it does not have to focus on drugs and alcohol or parental difficulties. Then it can allow the child to have concerns of their own, beyond their parent and separate from them. At the same time, the subject of drugs and alcohol and the effect they may have on children can be spoken about with children and their parents and expressed, and not become taboo. Children who have had addicted parents have often been very relieved indeed to speak about the difficulties that they have had to face – the fear, uncertainty and betrayal around the dangerous behaviour of a mother, the violence of a father, the frustration of trying to relate to a person who it is impossible to reach and subject to highly contradictory was of treating someone.

Thinking again about the girls’ depiction of a drunken mother in the play given above, we can see how taking on this role was the beginning a process. They were beginning to play with the serious issues in their life, where they could take on different roles within the drama – mother, daughter, child and see how they interacted

9 : Dramatherapy as a provider of psychological space for a child affected by alcohol or drug misuse

Dramatherapy can potentially offer psychological space to a child through the way it combines a therapeutic relationship with the opportunity to play, embody characters and create stories and dramatic images. It thus provides a flexible way of supporting a child, who may be wary of what to talk about or unsure about how they feel about what has happened to them. Drama in itself has a range of key ideas – for example the idea that telling a story and watching it can be important and transformative. As an imaginative discipline, drama allows a child to play and make their own stories and characters. This helps find creative expression for difficult experiences. Charlie demonstrated this in the way she explored issues of abandonment through her play with animals at the pet shop. However, like child psychotherapy, it can do this through the medium of relationship – the movement in Charlie’s play from darker troubled images of aggression, exclusion and abandonment to serene scenes of contentment and eating wholesome food whilst being well cared for show how important this relationship can be as a means for a child to gain recognition and nourishment.

Dramatherapists are able to switch perspectives between drama and life – Phil Jones talks about the life-role bridge as a core component of dramatherapy (Jones 1996). He refers to points at which the relationship between an enacted fantasy and a person’s life situation can become clear. However, metaphor may be something other than a convenient translation of life events into images. Swanepoel describes metaphor as “ a presence rather than a technique.” (Swanepoel 2012) . However, the images that a child produces, by being produced by the child within an attentive relationship allow this crucial element of psychological space for a child. Paradoxically it may be only when this space is challenged that it is defined. The case of Mark, illustrated below, shows how Dramatherapy can be effective even when a child does not want to play or create drama or dramatic images.

11 : The Power of Fury – Mark

Mark was referred to our project as both his parents had experienced heroin addiction. Mark was in trouble at school, he was excluded for violent conduct at around the start of our meeting. However, as our time together progressed, the therapy at times touched on his own neglected vulnerability – the child that seemed to need protection by this ultra violent persona.

The drug use of his parents had been such a major part of Mark’s life that he had become blase about it. Unlike some children who come to therapy feeling confused or unsure of how they feel, Mark was sure – he felt angry. It seemed to me that he wanted to face down his parents drug problems, and to not have to feel silenced by it. He marked the persona out it out in one session using a death’s head skull. The skull stood in front of Kenny from South Park – Kenny is a child who hides inside his hood with only his wide eyes showing, and is so vulnerable that he dies at the end of each episode. In between the two he placed an amber dot, that represented a neutral point between the two. He had been able to give space to parts of himself he felt shameful – not his violence which he was ambivalently proud of – but his frightened child and a kind of mediating neutrality.

This was the only time that Mark wanted to use representational imagery, or use imaginative techniques explicitly during our months of sessions together, so it seemed important.

Fantasy, and story telling did not seem to be something that Mark wanted to take make use of. However, listening to them carefully, as a dramatherapist meant for me to think about how he was telling his story. I wondered what role he was taking in his life and how able he might be to shift between understanding the perspectives of the other people in his life and within himself. Through dramatherapy Mark had access had the chance to tell his story to another person and so feel the full force of his fantasies without identifying with them fully. As he returned to his story each week, his violent fantasies sounded more like a story he was within and less as a literal expression of what he was going to do. By reflecting on what he said from my position as a therapist that could show concern for all sides, I felt I could allow his sense of his story to have more depth. I sifted through with him whether the things he was talking about were an actual risk for someone else or not, and express an adult concern for his and other safety. I felt it was important to do this in a way that combined space for and interest in his fantasies with concern for what would happen if they were literally enacted. In this way, I could help him to allow them to become fantasies and they could be put back into their right place, as legitimate responses to the complex pressures his parental addiction had placed on him. I could also act as an auxiliary for the part of him that urged restraint. In part this was through identifying the underlying drama in what he spoke about; recognising the different characters speaking within what he was saying, supporting the vulnerable ones and giving space to the powerful destructive ones. In this way, our conversations acted to give shape to his fury without denying it. In this way, he could sustain a relationship with me. I felt that my concern for him could reach him, rather than be dismissed as something that would leave him feeling dependent and weak.

12 : Reflection : The Dramatic Images of children with drug and alcohol problems in their family.
To give space to a child’s dramatic images is to allow dysfunctional patterns to have a place in the world – dramatic images return to what is dysfunctional and difficult with repetition and in great detail. In this way they are like Hillman described the psyche – a watchmaker that returns obsessively to its images working and reworking them until they are complete (Hillman 1983). A child may not find their unique sense of character and resilience either in a secure and predictable relationship, or by having a unique sense of their own creativity alone, but through a combination of these elements bought together. Charlie and Mark had different experiences of having drug or alcohol misusing parents, coming to dramatherapy at different stages in life. Charlie was able to play with the images that she carried with her; of being a pet from a pet shop that was not wanted and of relationships that swung from friendly to suddenly aggressive. She enacted all of this unselfconsciously and spontaneously, and dramatherapy provided a frame for her in terms of a relationship and access to reciprocal dramatic play.

For Mark, the situation was more complicated. He felt uncomfortable and blocked opportunities to use creative mediums. This may have also reflected the danger that play and spontaneity represented to him by revealing the part of himself that he needed to protect – his vulnerability as a child. Yet, at times, he was able to touch on these themes with me and show insight into them. The value of dramatherapy in his case was to have the therapist as a reflective audience, to allow him to de-literalise the story of his life, by beginning to review his violent fantasies as metaphors rather than as things which he could do at any moment if he snapped. The dramatherapy had to be found in the drama of his life, rather than the metaphorical exploration.

Children who have parents with drug and alcohol problems are often in a difficult position. They are more likely to be isolated- often from the kinds of relationships which would help them to moderate their own experiences. They can be required by their parents to take on roles that other children would not expect – acting as young carers, or perhaps even through more visible “bad” or angry behaviour in demonstrating a kind of emotion complicity with their parents’ volatility. At the same time they can carry enormous resentments of their parents that can fester and become internalised. Dramatic images engage a young person with the issues in their life in the best way that they can, not because drama is a great technique, but because these metaphors can be seen as more like presences that a child carries with them. For Charlie the process was largely spontaneous and unconscious, as she moved from playing with images of abandonment to images of security. Towards the end of therapy Mark said after describing a violent fantasy “I am not really going to do it”. This statement seemed important to me, suggesting Mark could develop a new, more mature relationship to his fantasies. In that moment they could be what they were : powerful expressions of a child’s fury.

13 : Conclusion : Dramatherapy’s place in the treatment of children affected by drug and alcohol problems in the family

Children affected by drug and alcohol problems need their own psychological space as they are often caught in the middle of toxic and confusing dynamics. They have often been isolated through their parent’s drug or alcohol related distress. They can be isolated in many ways – from healthier ways of relating, from being able to play, from access to straightforward chances to develop. More than this, they are likely to carry an internal wound that is the echo of their parent’s, and that can repeat the destructive patterns of their parent as they become mature.

Professional responses to children – risk assessment, understanding social psychological factors and forming healthy relationships with children show the range of responses to the problem these children face.

Dramatherapy can work with these professions to provide a child with the opportunity to tell their story within an attentive relationship. Being able to play with another, to be allowed to find the right expression, to be given the freedom to find that expression even when it seems unpleasant or frightening is an important part of what dramatherapy offers. This is what links the two cases of Charlie and Mark despite their difference in age and gender- that drama became a separate kind of place, where the images that they carried around with them could find a home. For George the medium was play, for Mark, conversation. The freedom to imagine and play can create that psychological space. This space can either be accessed directly through the psyche’s own language – metaphors and dramatic images through play – or indirectly within a conversation about life events, to find the metaphors within these, and the space that comes with them. As Cattanach writes: “What is universal in this process is not the psychotherapy, but the dramatic play.” Using dramatherapy’s ability to help a child make use of their imagination can be like diluting a drink that has been too concentrated. It can help transform the toxicity that a child has imbued from its parent’s attempts to self medicate into something more like medicine.

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